Concurrent Review Nurse

GuideWell Source

Concurrent Review Nurse role at Florida Blue focusing on evaluating hospital benefits and coordinating care for members in various healthcare settings. Collaborating with medical teams to ensure appropriate level of care.

Posted 7/30/2026full-timeRemote • Florida • 🇺🇸 United StatesJuniorMid-Level💰 $71,200 - $89,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical evaluation for benefit determination and medical necessity, with a strong focus on care coordination and collaboration within healthcare settings. Proficient in utilizing medical necessity criteria and managing discharge planning processes.

Highest-signal resume keywords

Clinical EvaluationCare CoordinationDischarge PlanningRegistered Nurse LicensureUtilization Review

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Benefit DeterminationMedical Necessity EvaluationCare Program IdentificationInterQual CriteriaCase ManagementAcute Care ExperienceRehab ExperienceSkilled Nursing Facility ExperienceHome Health Care ExperienceDischarge Status Assessment

Soft Skills

CollaborationCommunicationProblem-SolvingInterpersonal SkillsOrganizational Skills

Tools & Technologies

MS WordMS Excel

Certifications & Qualifications

Registered Nurse - State LicensureCompact State Licensure Florida

Industry Keywords

Healthcare IndustryManaged CareUtilization ReviewAcute ServicesNon-Acute ServicesOutpatient ServicesCommunity Resources

About the role

Key responsibilities & impact

Serve as a point of contact for providers to assist in navigating members them through the continuum, educate regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and network access
Evaluate members in the Hospital, Skilled Nursing Facility, LTAC, Acute Inpatient Rehab for benefit determination, medical necessity and appropriate level of care utilizing member benefits and InterQual or other medical necessity criteria.
Participate in weekly case review
Determine member's discharge status and identify and coordinate any additional needs and services that require ongoing Care Coordination services
Collaborate with Medical Directors, Managers, Co-workers and other departments including Case Management and Care Partners
Other duties as assigned

Requirements

What you’ll need

2+ years related work experience.
Experience Details: Recent (within the past 3-5 years) clinical experience in a hospital, LTAC, Rehab, SNF setting evaluating hospital benefit determination, medical necessity and appropriate level of care
Related Bachelor’s degree or additional related equivalent work experience Nursing
Registered Nurse - State Licensure And/Or Compact State Licensure Florida
Experience in one or more of the following: home health care, rehab, SNF, utilization review, discharge planning or case management Referrals for possible
Case Management activities that focus on acute and non-acute services, outpatient services and/or community resources
Experience with the Healthcare industry and Managed Care Experience in MS Word and Excel Moderate to heavy keying required
Occasional travel within the State of Florida

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Income protection benefits: life insurance, short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off, volunteer time off, 10 holidays and 2 well-being days
Additional voluntary benefits available; and a comprehensive wellness program